W I R T H L I N W O R L D W I D E
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Abstract
Health care providers and Spanish speaking patients interact with a health care system that they describe as mediocre at best. Faced with a language barrier that impacts the outcomes of health care delivery, providers see the issue of accommodating Spanish speakers within the health care system as a very important priority. Similarly, a large majority of Spanish speaking patients agree that the care they received is compromised when providers neither speak Spanish nor offer translators. There is a consensus on both sides of the communication exchange that the health of this community is put at risk due to these language barriers and current approaches to surmounting them.
While there is no clear consensus on where responsibility for language accommodation falls, it is clear that the health care system in its present form is not adequately meeting the needs of Spanish speaking patients. Most often, patients feel that the language barrier limits the effectiveness of the care they receive and makes achieving positive outcomes more difficult because they are unable to explain their problems and understand treatment options. The problem so inhibits the communication process between patient and provider that one in five Spanish speaking patients has not pursued care when needed due to the language barrier.
Providers attempt to overcome the language barrier with a “triage” approach of sorts – by using staff members, often a nurse or janitor, to translate, or to rely on the patient to bring along someone who speaks English. Relying on this informal and haphazard process fosters a communication exchange that providers see as incomplete and less than accurate. The language barrier and use of largely un-trained intermediaries makes it harder for patients to understand treatment advice and for providers to get an informed picture of the problem and symptoms at hand. Providers say that the main barrier to doing more to overcome the language barrier is cost.
Patients and providers alike believe there are solutions that can help mend this problem. Ideas include using trained interpreters, providing staff and patients with materials and instructions translated into Spanish, and having staff members on hand that are bilingual. While interpreters make the communication chain easier to facilitate, many patients are concerned about the current practice of using translators
(such as family, friends, or office staff) to communicate with their providers. They stress the importance of a direct communication exchange. In the end, both providers and patients are trying to find the best solution to overcome this problem, but will require help in figuring out the best way to proceed.
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Background & Method
The Robert Wood Johnson Foundation asked Wirthlin Worldwide to help them understand how language barriers affect the quality of health care given to patients who are Spanish-speaking, with little or no English abilities. To meet this goal,
Wirthlin Worldwide interviewers spoke with health care professionals and Spanish speaking Latinos in October and November of 2001 about the issue of health care in order to set the backdrop for the Hablamos Juntos: We Speak Together initiative. Two surveys were conducted via telephone: one among 500 members of the Spanish speaking public and the other among 1,002 health care providers who practice in a variety of settings (i.e. hospital emergency rooms, clinics, office based practices, pharmacies) and medical specialties split among the following segments:
Number of Interviews
Doctors
300
Nurses
301
Executives
200
Pharmacists
201 o Both health care professionals (doctors, nurses, executives, and pharmacists) and members of the Spanish speaking public were residents of metropolitan areas across the United States where Latinos comprise over 5% of the general population and have experienced growth over 75% between 1990 and 2000. o For providers, at least 5% of their patient base was primarily Spanish speaking. Interviews were conducted during business hours. o For patients, respondents were familiar with the health care system – having visited a doctor at least once in the past year - and considered Spanish to be their primary language. They indicated they would have significant difficulty communicating with a health care provider in English. These interviews were administered in Spanish and completed in the evening and on weekends.
Quality Backdrop
To set a context through which to evaluate the health care system, both providers and members of the Spanish speaking public were asked to evaluate the current state of quality in the health care system.
Overall, the health care system earns a mediocre grade for quality from both parties.
Providers give the system a higher quality grade than the Spanish speaking public
(44% of providers say the system is very good/excellent vs. 27% of the Spanish speaking public). Patients make no clear distinction on quality levels between na-
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tional and local health care. To them, both systems have significant room for improvement.
Providers Have More Favorable Perceptions of Quality
Than Spanish Speaking Public
- Provider Data / Spanish Speaking Public Data -
Providers
Ve ry
G o o d /
E x c e lle n t
4 4 %
Spanish Speaking Public
Ve ry
G o o d /
E x c e lle n t
2 7 %
G o o d 3 8 % G o o d 4 3 %
No t G o o d 1 8 % No t G o o d 3 0 %
PQ2/HQ2: Please think broadly about the quality of health care offered in the United States today. By quality we mean health care that is safe, effective, patient-centered, timely, efficient, and equitable. Would you judge it to be: …
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When looking at health care providers in greater detail, it becomes evident that hospital executives and physicians have the highest perceptions of health care quality, while nurses and pharmacists judge the system a bit more critically. (% judge quality excellent/good)
55% hospital executives
48% physicians
40% nurses
34% pharmacists
Issue Context
There is a clear consensus among health care providers that patient-provider communications is of utmost importance in trying to provide the highest quality care possible (94% say the issue is very important to providing quality care). Communication is seen as a driving force behind patient outcomes and the issue most compromised when a language barrier exists.
It’s evident that providers see helping Spanish speaking patients better benefit from the health care system as an important priority. Nearly 7 in 10 (68%) see the issue as a top or one of a number of important priorities.
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In a related response, a large majority of Spanish speaking Latino patients agree that care is compromised and positive outcomes are made more difficult when providers neither speak Spanish nor offer translators.
7 in 10 Providers See Issue as Priority; Majority of
Spanish Speaking Latinos Say Care Compromised
Provider Data
Spanish Speaking Latino Data
10%
58%
Top priority
One of a number of important priorities
68%
Top/Important
Priority
68%: Positive outcomes are made more difficult when providers neither speak
Spanish nor offer translators
PQ5: Among all the issues currently facing the health care delivery system, how much of a priority should helping primarily Spanishspeaking health care consumers better use and benefit from the health care system be? Do you think it should be …
HQ12: Now, please think about a time when you were with a doctor, nurse, pharmacist or other health care provider who only spoke English and there was no translator available. Please tell me for each of the areas, was it …
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Taken together, these findings indicate that the language barrier that often exists between health care providers and their patients presents significant problems that impact the health of this community.
Providers see significant opportunities to improve the system’s ability to accommodate its Spanish speaking patients (only 9% say that we are currently doing this very well). Almost half of all providers, feel that the current US health care system as we know it is not set-up to help Spanish speaking Latinos function within the system.
We observed some internal inconsistencies among members of the Spanish speaking population who were reluctant to show criticism of the system. These Spanish speaking patients give positive reviews with 72% saying they feel the system accommodates them very/moderately well, despite the finding that the vast majority of these patients are faced with provider alternatives in their community that generally do not speak Spanish or offer translators. Only 36% of patients say that half or more of the health care professionals they visit locally speak Spanish or have someone on their staff that can translate.
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Patients Say System Accommodates Them Well, Despite
Community Lacking Provider Alternatives that
Speak/Translate Spanish
-Spanish Speaking Public Data -
Spanish-Speaking Public
3 1 % V e r y w e ll
M o d e r a te ly w e ll
4 1 %
N o t v e r y w e ll 1 7 %
36% Half or more of local health care professionals speak Spanish or have someone on their staff who can translate
7 % N o t w e ll a t a ll
HQ3: Overall, how well do you feel the health care system is set up to accommodate this group?
HQ3: Overall, when you visit health care professionals and pharmacists in your community, how many do you find are able to speak Spanish themselves or have someone on staff that can help with translation or interpretation
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Issue Responsibility
Is there a consensus on where responsibility for language accommodation falls? Is it more the patient’s responsibility to be able to function in the existing system, or more the provider’s responsibility to facilitate that functionality? There isn’t a clear answer.
While both providers and patients are split on the topic of assigning responsibility, providers slightly more often feel that they carry heavier responsibility for the problem (60%) than do their patients (40%). When talking with the Spanish speaking community, even less of a mandate is evident. Half of the Spanish speaking public feel that it is the provider’s responsibility to accommodate their language needs
(49%), the other half (48%) feel it’s the patient’s responsibility to better function in an
English speaking environment.
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There is a great deal of consistent thinking across provider sub-segments throughout the research. One difference worth noting, however, is the variation in the degree of priority given to the issue, and also the sense of responsibility felt to drive solutions.
Hospital executives and nurses place the highest priority on the issue and also more often accept primary responsibility for accommodating the language barrier. Physicians and pharmacists indicate less urgency for the issues overall, and correspondingly more often feel it’s the patient’s responsibility to function within the existing system.
% top/important % provider’s responsibility
Priority
Executives 79%
Nurses 76%
Physicians 60%
Pharmacists 57%
To accommodate
75%
72%
45%
50%
Language Barrier Issues: Spanish Speaking Patient Perspective
From a patient perspective, there is a clear sense that the language barrier that exists compromises the effectiveness of their care and positive outcomes are made more difficult. Most often, this language barrier impacts communication related outcomes, most specifically:
% More Difficult when with
Ability to fully explain symptoms/ask questions
Ability to follow through with filling
English-speaking only provider
80%
71% prescriptions
70% Trusting doctor understands your medical needs
Ability to understand doctor’s recommendations
67%
Seeing doctors as often as needed 64%
Q: Now, please think about a time when you were with a doctor, nurse, pharmacist or other health care provider who only spoke English and there was no translator available. Please tell me for each of the areas, was it … (degree of difficulty: Much more difficult, a little more difficult, no different)
The net effect of this communication problem is striking. One in five Spanishspeaking patients say that they have not pursued care when needed because the provider neither spoke Spanish nor provided someone on staff to interpret. Instead, these patients opt to remove themselves from the resources the health care system provides.
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One in Five Have Gone Without Care When Needed Due to Language Obstacles
Spanish Speaking Latino Data
19% Have Not sought care when needed due to language barrier
HQ11: In the course of the past year, how many times were you sick, but decided not to visit a doctor because the doctor didn ’t speak
Spanish or have an interpreter?
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Language Barrier Issues: Provider Perspective
Providers also feel that language barriers negatively impact health outcomes for
Spanish speaking patients and that care outcomes for these patients who only speak
Spanish are compromised. The top areas providers cite as problematic due to a language barrier focus on the completeness and accuracy of the communication exchange, in addition to challenges faced when medical or treatment histories aren’t accurate or complete.
%Top 2 Box: outcomes significantly compromised when language barrier is present
52% Patient’s ability to fully understanding doctor’s treatment advice and medical condition/disease
Increased risk when medications or home remedies being used are not discovered
Ability to fully explain symptoms, prob-
51%
51% lems and concerns to provider
Incomplete or inaccurate medical history
Follow through on doctor recommended advice
50%
43%
Q: When you think about aspects of health care that are compromised due to the existence of a language barrier, which aspects are most compromised? Please indicate the degree of compromise you feel a language barrier has on outcomes for each aspect mentioned. Use a 7-point scale, where 1 means “language barrier does not compromise outcomes at all” and 7 means “language barrier compromises outcomes significantly.”
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Current Approach
While the majority of providers say they have someone on staff who can help with interpretations for Spanish speaking patients, that person isn’t always necessarily a medical professional. At provider organizations, staff in all positions – from nurse to janitor – are relied on for help with interpretation and translation as a “band-aid measure.” Also common is relying on the patients themselves to bring along a family member or friend to translate the exchange. Overall, the provider process of accommodation is informal at best.
Current Translation Approach Relies Heavily on
Informal Methods
Provider Data
Staff such as doctors, nurses, clerks help with translations
“I grab a Spanish-speaking employee and ask for help.
”
5 1 %
Patients Bring Family/Friends to Translate
“We don't have a set protocol…We use family members.
”
2 9 %
1 5 %
4 %
Retain external group to provide interpreting services on-site or remotely
Foreign language training for health professionals offered
PQ10A-A: There are a number of ways interpretive services can happen in health care organizations. I ’m going to describe four models.
Please tell me which best describes how your organization currently operates.
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The results of relying on this informal system of accommodation have clear negative consequences. Providers do feel that the system falls short, most specifically by perpetuating barriers that do not allow them to communicate effectively with their patients. Providers also recognize the lack of interpreters available, problems treating patients given the communication question, and a lack of bilingual staff as other impediments. In providers’ own words:
“I think that because the patient cannot communicate with the provider they do not get the quality of care that they deserve.”
“It’s still hard to find interpreters at the time of service.”
“If you cannot communicate with the patient you cannot adequately prescribe.”
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“We don’t have physicians that speak Spanish. We have support staff, but not the primary physicians.”
According to providers the main barrier to doing more to address the language barrier issue is cost. More than half of heath care providers (53%) see money as the main reason why more steps aren’t being taken to address this growing problem.
Solutions
Both providers and patients agree that there is a problem that needs to be addressed and fixed, and suggest a variety of solutions.
When asked directly about a number of solutions that could be implemented, patients say it would be most helpful to have:
1.
Trained interpreters to tell the doctor everything patients say;
2.
Doctor’s office staff that can explain appointments and exams in Spanish; and
3.
Being provided with standard care instructions translated into Spanish.
Despite the call for interpreters and other intermediaries, patients have strong opinions about the importance of communicating directly with their providers. Almost all Spanish-speaking patients say it is very important to talk directly with the provider, and a strong majority (65%) have concerns about dealing with an interpreter.
These concerns are primarily focused on the clarity/accuracy of both sides of the communication exchange and issues pertaining to privacy.
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Based Upon Current Practice, Two Thirds Have
Concerns When Using Interpreters
Spanish Speaking Latino Data
65% have concerns about using an interpreter
Concerns
• Interpreters wouldn’t explain things to patient clearly
• Interpreter would omit info/not tell everything
• Patients wouldn’t tell the whole truth
• Privacy
• Embarrassment
• Interpreters would use terms that are new or unfamiliar
• Interpreter doesn’t understand patient
• Doctor will look at/talk to interpreter, not patient
• No Trust/Confidence in Interpreter/Doctor communication
• Patient wouldn’t talk about personal things when interpreter present
HQ16: Some people have concerns about using a interpreter during a doctor visit, others don ’t. What specific concerns, if any, do you have about having an interpreter help doctors and patients communicate?
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Providers take a similar approach as patients when envisioning solutions for the problem. They also seek solutions that focus on staff’s language abilities and the use of interpreters. In fact, one third mention language training for staff in Spanish (including medical Spanish), as something that would be valued. When asked directly what would be most valued, providers most often point to:
1.
Offering Spanish language standard care instructions;
2.
Offering Spanish language materials/tapes; and
3.
Receiving funding to develop medical interpreter capacity.
Beyond the immediate “fix” of prepared materials, health care providers look to interpreters to bridge the problem. In their own words:
“Using professional translators – people who understand every nuance of the language.”
“The use of trained interpreters and less reliance on a person who works in the hospital like a clerk, or cleaning staff because of confidentiality – so we bring in trained, professional interpreters.”
“(Interpreter) training in medical Spanish is critical.”
Ultimately, both providers and patients need help in figuring out the best way to overcome this growing problem -- a problem that clearly has a negative impact on the health of a large community.
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